by Kerry Tuschhoff, HCHI, CHt
What most expectant parent don't realize is that they truly are in charge of their baby's birthing. They get to choose the way the labor and birth go, as well as their baby's care after birth. It is no different than any other service that you pay for, except that it is much more important. You are paying the doctor's nurse's and other staff's salaries, and you deserve to get what you want. If there are true complications, that's when the doc, midwife or nurses step in and help. Just like being a Lifeguard at a pool: No one needs to do anything except keep a watchful eye on things, and if anyone's in trouble, that's when they jump in to help.
Routine vaginal exams
Routine vaginal exams are very common in late pregnancy
Benefits: A routine vaginal exam at the end of your pregnancy actually has no benefits since your present dilation/effacement/station are not indicators of when your birthing time will begin.
Risks: There is a small risk of infection and PROM (Premature rupture of membranes) (See Henci Goer's The Thinking Woman's Guide to a Better Birth for realities for related studies pgs 204-209) Stripping of the membranes is often done as well during a routine vaginal exam, (see below) and can cause many days of cramping, bleeding and possible sleep loss without any benefit.
Alternatives: You can tell your care provider that you would prefer not to have one. And keep your panties on.
vaginal exams measure several things:
- Dilation & thinning of the cervix, at that time
- Position of the baby, at that time
- Station of the baby, at that time
- Position of the cervix, at that time
Vaginal exams do not measure:
- When the baby is coming
- Whether the baby will fit through your pelvis (in most cases)
- All the progress being made before or in your birthing time
Vaginal Exams during the Birthing Time
"Let's see how far along you are." Vaginal exams are administered in your birthing time to assess dilation of the cervix.
Benefits: This really has few benefits, as it tells you nothing about when the baby will be born, but has some risks. Having a vaginal exam when you feel "pushy" may be of help to ascertain if you are fully dilated.
Risks: Every time an attendant checks the mother's cervix, the risk of infection is increased, especially if her bag of waters is broken.
Vaginal exams may also cause the mother to tense up, and her ability to relax is reduced. Some women like to find out how far they are dilated, but this is not a reliable way to figure out how long a she has left. In fact, it might discourage her if she finds out she is dilated less than she imagined, and this emotional element is very important. If a woman is not dilating quickly enough, interventions may be instituted. This puts additional stress on the birthing woman.
Aside from obvious risks, vaginal exams can be very uncomfortable, especially if performed during a surge. (Ed.: Before one is done, take a deep breath and as you exhale, concentrate on your "Anesthesia" programming, "seeing" the anesthesia all around your cervix, and relaxing your pelvis.) Further, it is impossible to predict how long your birthing time will last from how far a woman is dilated. It would be well advised to pay attention to emotional signposts instead. They give a lot more clue to where a woman is progressing in birth.
Stripping the membranes
A procedure called "Stripping the membranes? consists of separating your bag of water from your cervix, during a vaginal exam. It may be done without your consent or knowledge, and this can be avoided by talking to your doctor before any internal exam.
Benefits: Some believe that it will bring on birthing surges within 24-48 hours. There is no scientific data to back this theory up.
Risks: There is a risk of infection and premature rupture of membranes, and it may be painful.
Alternatives: You can tell your care provider that you would prefer not to have the procedure done.
Inductions are becoming increasingly common for varying reasons. There are no studies to prove that routine induction regardless of gestational age improves perinatal outcome. The average length of gestation for primiparas (first pregnancy) is 274 days and multiparas (second and beyond pregnancy) 269 days from ovulation so that translates to 41 weeks 1 day for first time moms and 40 weeks 3 days for subsequent babies. Research evidence shows that induction for "suspected big baby" results in higher c-section and operative vaginal delivery rates than waiting for the birthing time to start on its own, and there is no evidence that larger babies pose a bigger risk of problems during birth. Furthermore, there is currently no way to assess how big a baby will actually be at birth, and ultrasound is often erroneous by several pounds.
Benefits: When medically indicated an induction can improve the perinatal outcome. Medically indicated reasons would not include you being past 40 weeks or a suspected large baby but rather a physical problem with you or the baby, a BPP (Biophysical profile) indicating a possible problem, or a Stress or Non-Stress Test indicating a possible problem. Keep in mind that these tests are meant for a prolonged pregnancy and they have a high false positive rate. This is not a cut and dry subject; there are many variables, and for this reason it is very important to have a care provider you trust and be as educated as possible.
Risks: It may not work, and your chance of getting a Cesarean Section are higher than if you would have gone into your birthing time spontaneously.
Alternatives: There are many natural ways of inducing birthing waves such as using hypnosis, nipple stimulation, intercourse, herbs, enemas, castor oil, etc.
Amniotomy is the artificial rupture of the membranes with an amniohook (AROM). An Amniotomy can be done to either induce birthing surges or at some point during the birthing time.
Benefits: If it is done later in the birthing time it can get a stalled one started again.
Risks: There are quite a few risks involved with Amniotomy. The amniotic fluid provides a cushion for both you and the baby, therefore making the pressure surge more comfortable, and the baby's head protected from compression. The baby can get stuck in an unfavorable position because he/she can not maneuver as easily with the amniotic fluid gone. There is an increased likelihood of umbilical cord compression or cord prolapse, where the umbilical cord gets flushed out with the water when it breaks and gets kinked like a hose. Due to the sterile field of the amniotic sac being broken you also have a higher risk of developing an infection. From the time you have an Amniotomy you are on the "clock" so to speak. A lot of care providers require birth within 24 hours regardless of method. Also you may be restricted to bed and you will be restricted from showering and/or bathing.
Alternatives: It depends on what your care provider wants to accomplish with AROM. If they suggest AROM to speed the birthing time up or get a stalled one going again and your baby is showing no signs of distress, you can simply give your body time to do what it was made to do, or use natural birthing stimulation techniques. If they suggest AROM to induce birthing surges you can use Evening Primrose Oil, nipple stimulation or other ideas. There are many. Read more about amniotomy.
Pitocin is commonly used to induce birthing surges or increase the strength and/or duration of them. There are some problems associated with the use of Pitocin:
Pitocin was designed to simulate the body's natural oxytocin, which is released in bursts, however Pitocin is administered through an IV in a continuous stream, and because of this the pressure surges are unnaturally strong, peak longer and may result in decreased uterine blood flow which can cause harm to the baby, and tetanic pressure surges, which can cause uterine rupture.
Benefits: Pitocin inductions only work when your body is ready for birth; you may want to check your score on the Bishops Chart to gage the likeliness of a Pitocin induction being successful.
Risks: Pitocin can start the domino effect - IV, Pitocin, external fetal monitoring, lack of mobility, diminished ability to deal with pressure surges, pain medication, weaker surges due to narcotics, then more Pitocin, fetal distress, etc. Cons for the birthing mother include much more discomfort and prolonged difficult pressure surges, which may cause premature separation of the placenta, rupture of the uterus, laceration of the cervix or postpartum hemorrhage. Cons for the baby include fetal asphyxia and neonatal hypoxia from too frequent and prolonged uterine pressure surges, physical injury and prematurity if the due date is not accurate.
Alternatives: It depends on what your care provider wants to accomplish with Pitocin. If they suggested Pitocin to speed birthing surges up or get a stalled birthing time going again you can try walking, changing positions, nipple stimulation and of course make sure you are well hydrated and nourished. If they suggested using Pitocin to induce, you can try walking, nipple stimulation, intercourse (if your waters are intact) and many other natural induction techniques. If none of those work it is likely a Pitocin induction would also be unsuccessful. Read more about pitocin".
An Episiotomy is a surgical incision in the perineum (the area of skin between the vagina and the anus). It is the equivalent to a 2nd degree tear. There is no reason to have one done in a normal vaginal birth (by that I mean non-operative).
Benefits: Episiotomies are said to speed up the birth by 5-10 minutes, prevent tearing, protect against incontinence, and are said to heal easier than a tear. There is no scientific evidence to back these theories up.
Risks: Infection, increased pain, increase in 3rd and 4th degree vaginal lacerations (extensions into the rectum), significantly longer healing time and when sexual intercourse is resumed, there is increased discomfort.
Alternatives: Don't get an Episiotomy. When you talk with your care provider ahead of time about your birth plan be sure to include what you would like your care provider to do regarding this issue (you can specify that you would rather tear naturally if it came down to that). Ahead of time you can do Kegels, you can request warm compresses on your perineum while your baby's head is crowning, and push slowly all of these will lessen your chances of tearing. (Ed.: At crowning you can ease the baby's head out in between surges! -- more on this later) More Episiotomy Resources.
**(What is a true indication for an episiotomy? A tear that is starting to go up into the peri-urethral area, or fetal distress.)
Continuous Electronic Fetal Monitoring
This method provides beat to beat view of the baby's heart tones, in relationship to mother's pressure surges on a continuous basis. This is a benefit for the high risk mother, but of questionable benefit to the low risk mother.
Benefits: There is NO proven benefit to continuous EFM over periodic checks of Fetal Heart Tones -- birth outcomes have been shown to be the same whether EFM is used, a hand-held Doppler or a non-electronic fetoscope; Intermittent Fetal Monitoring can be safely used during the birthing time.
Risks: This method does use ultrasound; leaves room for mechanical error, which may cause incorrect interpretation, unnecessary interventions etc.; loss of maternal mobility (when in use), and/or trouble with the baby descending properly, which is often aided by movement, which may slow your birthing waves; and may switch attention from the mother to the machine.
This is sometimes more accurate than the electronic monitoring, does not use ultrasound, and can provide continuous monitoring for the high risk mother. It is done by screwing an electrode into the top of the baby's head and placing a probe into the vagina/uterus.
This method requires that your water be broken (An amniotomy will be performed if your membranes are still intact.), and that you be 2-3 centimeters dilated. Amniotomy adds risks of its own. However, the risks and benefits of each procedure must be weighed.
Benefits: This type of monitoring is mostly used in high-risk situations or when more accurate types of monitoring may prevent other unnecessary interventions.
Risks: Internal monitoring has been associated with fetal injury (from the electrode), high rate of infection for mother or baby, and also severely restricts movement. It could damage baby elsewhere if the top of the head is not the presenting part.
Alternatives: If there is not a high risk situation or emergency happening, you can choose to be monitored with intermittent EFM. For more information, read Internal Electronic Fetal Monitoring.
Epidural anesthesia uses repeated doses of a local anesthetic in the epidural space of the spinal area. It numbs the nerves from the uterus and birth passage without stopping the birthing surges.
Benefits: Epidural block provides effective analgesia in many cases and can be used to lower a birthing woman's blood pressure if too high.
Risks: Aside from not always working, or providing "patchy" relief, epidurals often lower the mother's blood pressure too much, which decreases the amount of oxygen for the baby, increasing the risk of fetal distress. Occasionally the medication is placed erroneously in the spine and goes up instead of down, creating respiratory failure or distress in the mother.
Often the mother's temperature rises (Epidural Fever) and can lead to hypothermia of the baby in which case a full workup after the birth is usually ordered to rule out infection, and that often includes a spinal tap on your newborn. Also, although an attempt is made to time the epidural right so that it can wear off so the mother can feel her pushing efforts, it is tricky and often unsuccessful. Pushing while anesthetized not only makes pushing less effective, it robs the mother of urge to push, which (as opposed to full dilation) should be what dictates when pushing begins. This also often results in the need for forceps and vacuum, extraction birth, which carry their own risks
It also makes the perineal and vaginal muscles slack and unable to turn the baby after the birth of the head, and sometimes results in sexual dysfunction weeks and months later. In addition, an epidural is associated with an increased risk of needing Pitocin to augment pressure surges, and a Cesarean Section for failure to progress, as it often slows down birthing surges dramatically, as well as short and long term postpartum back pain.
Alternatives: There are other ways of reducing any discomforts of birthing. Many women are helped by techniques learned in childbirth classes - (Ed: YAY, Hypno-birthing!) relaxation, massage, positioning, visualization, hypnosis, distraction, focusing and breathing that are done with the support of another person. These non-drug coping skills use your own strengths and place you in control of your own body. For more information, read Epidural Express.
Coached pushing is when nurses or other caregivers can get quite enthusiastic about the Second stage of the birthing time and begin to direct it in loud, athletic tones, admonishing the mother to push as hard and long as she can, holding her breath while they count to 10 over and over, usually after putting the back of the bed down all the way so that the mother is actually pushing uphill.
Benefits: If the baby is at risk during the pushing stage, all efforts must be made to get it out quickly and this may help.
Risks: "Purple Pushing" will have the effect of actually closing off the Birth Path due to tension, and wear the mother out. Amazingly, a mother doesn't actually have to push much to get the baby out; the uterus will do the work well on its own. Each woman should do what her body tells her to do. Push gently with the surges, and relax fully in between.
"Purple pushing" also increases the risk of injury to the perineum.
In addition, between full dilation and actually feeling the urge to push there is often a resting phase. To tell a woman when she must push, especially if she does not feel the urge immediately, can lead to many problems. Breath-holding, it has been shown in studies, leads to lowered umbilical artery pH, abnormal changes in fetal heart rate and lower Apgar scores.
Alternatives: Make sure your caregivers know that you are pushing in a completely mother-directed way, thank them for their help, but ask for some time alone to get into your own rhythm. If you want to avoid tearing, push gently, or "breathe the baby out."
Disclaimer: Hypnobabies Network, and Kerry Tuschhoff assume no responsibility or liability for the outcome of any pregnancy, labor, or birth. The content of the above information is in no way to be represented as medical advice, nor as a prescription for medical procedure. As always, you should seek the advice of a medical doctor or midwife to answer any health-related or pregnancy-related issues surrounding your pregnancy, labor and delivery, or before starting any new pregnancy-related program.
More Hypno-Birth tips...
Tip #1: Getting Started
Tip #2: Your Bubble of Peace
Tip #3: Why Create a Birth Plan?
Tip #4: A Sample Birth Plan
Tip #5: Laboring at Home
Tip #6: Do I need a Doula?
Tip #7: What to do in Early Labor
Tip #8: Getting everything You Want
Tip #9: Birthing Choices
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